Basic Information
| Provider Information | |||||||||
| NPI: | 1821429820 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANYON GOLF FAMILY DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20210 STONE OAK PKWY | ||||||||
| Address2: | TBD | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107872062 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20210 STONE OAK PKWY | ||||||||
| Address2: | 209 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107872062 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2013 | ||||||||
| LastUpdateDate: | 03/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | SOTO | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 2107872062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DD.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.